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To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1468-0408.2009.00487.x Byline: Denis Fischbacher-Smith (1), Moira Fischbacher-Smith (1) Keywords: organisational learning; adverse events; organisation with a memory; patient safety Abstract: This paper seeks to provide both a retrospective and prospective view on the issues surrounding the generation of adverse events within healthcare. It aims to deal with a range of issues around the individual as a means of making mistakes or violating the rules within the organisation. It sets the issue of patient safety into its historical context before highlighting the shift in thinking that accompanied the publication of an Organisation with a Memory (OWAM) by the Department of Health. The paper considers the challenges that surround the shift away from a person-centric approach to adverse events to one that recognises the importance of latent factors in shaping the conditions in which people can make mistakes and violate. The paper concludes by setting out several propositions for further research and the changes in managerial practice that are needed within healthcare in order to begin to achieve the core aim of OWAM which is to ensure that organisations remember and learn from adverse events. Author Affiliation: (1)Professor of Risk and Resilience and head of the Centre for Health, Environment, Risk and Resilience (CHERR) at the University of Glasgow Article note: Address for correspondence: Denis Fischbacher-Smith, CHERR, Department of Management, University of Glasgow, Gilbert Scott Building, Glasgow G12 8QQ, UK., e-mail: denis.smith@lbss.gla.ac.uk